Spinal Cord Injury Case Study 3v6j55
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At the Scene
All of Jonathan's friends are standing around him, unsure about what to do. They are afraid that he is badly hurt. Jonathan thinks it is just a temporary sting and states that he will be all right in a few minutes. One of the men calls 911 on a cell phone.
1. What should Jonathan's friends do while waiting for emergency personnel to arrive? A) Help Jonathan move his legs and assist him to sit up. INCORRECT No one should help Jonathan move his legs or assist him. B) Place a blanket over Jonathan and make sure no one moves him. CORRECT Any movement or improper handling could cause further damage and loss of neurological function. C) Attempt to stabilize his neck with any type of soft material. INCORRECT Any attempt to manipulate the neck could cause further damage and loss of neurological function. D) Carefully put Jonathan in the back of a truck with one man holding his neck. INCORRECT Any action that manipulates the neck could cause further damage and loss of neurological function. Points Earned:
0.0/1.0
Correct Answer(s): B
An ambulance arrives within a few minutes. Two paramedics and an Emergency Department (ED) nurse on a "ride-along" quickly take control of the situation. The nurse assists the paramedics as they prepare Jonathan for transport to the trauma center.
2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further? A) Logroll to side while maintaining neutral alignment. INCORRECT This action would be used to move an injured person from a prone position to supine if respiratory compromise occurs. It is not the best way to open the airway of a person who is already in the supine position.
B) Perform the jaw-thrust technique. CORRECT The jaw-thrust is the safest first approach to opening the airway of a casualty who has a suspected neck injury because in most cases it can be accomplished without extending the neck. C) Flex the neck with a wedge pillow. INCORRECT This action could cause further damage to the spinal cord as it stretches the back of the neck. D) Use the chin-lift/head tilt technique. INCORRECT This technique causes extension of the neck and could cause further damage. Points Earned:
1.0/1.0
Correct Answer(s): B
Keeping the head, neck, and spinal column in a neutral position, the paramedics and the nurse apply a cervical collar and place Jonathan on a scoop stretcher. A large bore IV is started and oxygen is applied at 8 liters/minute using nasal prongs. Jonathan is transported to the trauma center via ambulance.
Clinical Manifestations
When Jonathan is itted to the emergency department, the trauma nurse performs a neurological assessment.
3. Which intervention has highest priority when assessing Jonathan? A) Palpate the lower abdomen for any signs of urinary retention. INCORRECT Although urinary retention is assessed to help diagnose spinal shock, it does not have the highest priority. B) Assess sensation by gently pinching the skin distal to proximal. INCORRECT Although sensation is evaluated in this manner, this assessment does not have the highest priority. C) Assess Jonathan's breathing pattern and his ability to cough. CORRECT
Since a cervical spinal cord injury is suspected, the nurse must be aware that edema may ascend the spinal cord, which can compromise breathing and coughing. Breathing is always the priority, especially when there is the possibility that oxygenation might be impaired. D) Monitor the client's vital signs, especially a tympanic temperature. INCORRECT An autonomic disruption may cause an alteration in temperature, but this assessment does not have the highest priority. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse completes the ission assessment and documents the findings in the nurse’s notes.
4. Which assessment data warrants immediate intervention by the emergency room nurse? A) Jonathan has a slight sensation in his right metatarsals. INCORRECT The return of sensation in his toes is an excellent outcome that does not warrant any intervention. B) Jonathan's respirations are 20 and unlabored. INCORRECT Because the client's respirations are within normal limits for an adult, no intervention is needed. C) Jonathan's blood pressure is 96/60, and his pulse is 48. CORRECT Hypotension and bradycardia are signs of neurogenic shock. This is a medical emergency that warrants immediate intervention. D) Jonathan is complaining of a headache. INCORRECT Although Jonathan's headache may be due to his fall, further assessment is needed prior to intervening. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse recognizes that Jonathan is experiencing spinal shock.
5. Which intervention should the nurse implement first?
A) Assess Jonathan for symptoms of a paralytic ileus. INCORRECT Although a paralytic ileus can occur, it is not the priority intervention. B) Notify the emergency room physician immediately. CORRECT This is a medical emergency. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is imperative to reverse spinal shock as quickly as possible. C) Assist the physician to insert an endotracheal tube. INCORRECT Jonathan may need to be put on a mechanical ventilator, which would require the insertion of an endotracheal tube, but it is not the priority intervention. D) Prepare to ister the vasoconstrictor, dopamine. INCORRECT This may be necessary but this is not the first intervention. Points Earned:
1.0/1.0
Correct Answer(s): B
The trauma physician and ER team work to stabilize Jonathan's condition. The trauma team inserts a central venous catheter and a Foley catheter with a urimeter attached. When Jonathan's hemodynamic status improves, he is sent for a STAT Computer Tomography (CT) scan.
Continued Stabilization in the Emergency Department
The trauma physician writes the initial prescriptions for treatment.
6. Which medication should the emergency room nurse expect the physician to prescribe for Jonathan? A) Morphine, an opioid analgesic. INCORRECT Other than a headache, there is no data to indicate Jonathan is in pain. B) Mannitol (Osmitrol), an osmotic diuretic. INCORRECT This medication is used to treat increased intracranial pressure in a head injury. There is currently no data to a brain injury.
C) Methylprednisolone Sodium Succinate (Solu-Medrol), a corticosteroid. CORRECT This medication, when given within eight hours of injury, decreases inflammation, thereby reducing damage to cell membranes. D) Acetylsalicylic acid (aspirin), a nonsteroidal antiinflammatory drug. INCORRECT NSAID’s are not a treatment of choice for an SCI. Points Earned:
1.0/1.0
Correct Answer(s): C
The medication is prescribed as 125 mg IVPB over 30 minutes. The intravenous piggy back (IVPB) containing the medication contains 100 ml of fluid. The drop factor on the IV tubing is 10 gtts/ml.
7. How many drops per minute (gtts/min) should the nurse regulate the IVPB? A) 33 gtts/min. CORRECT Amount infused (100 ml) multiplied by drop factor (10) divided by minutes to infuse (30) equals 33 gtts/min. B) 50 gtts/min. INCORRECT the formula for calculating an IV flow rate. C) 100 gtts/min. INCORRECT the formula for calculating an IV flow rate. D) 125 gtts/min. INCORRECT the formula for calculating an IV flow rate. Points Earned:
1.0/1.0
Correct Answer(s): A
Nursing Interventions in the Neuro Intensive Care Unit
Jonathan is itted to the Neuro Intensive Care Unit. His cervical spine is stabilized with Gardner-Wells tongs, a Foley catheter is inserted, and he is placed on a kinetic bed. Jonathan is
alert and oriented and denies any pain or discomfort at this time. He is still unable to move any of his upper or lower extremities, and he has sensory deficits from the chest area down.
8. Which nursing intervention is included in the care plan when managing a client with GardnerWells tongs? A) Do not remove the traction weights and ensure they hang freely. CORRECT Traction is applied to the tongs by employing weights to maintain alignment. Removing the weights would result in misalignment, possibly creating further damage. Weights should hang freely so they do not interfere with the traction. Jonathan should also be assessed for evidence of infection at the spring-loaded pin sites. B) Ensure that an extra set of drill bits are available in case a new set of predrilled holes must be made in Jonathan's skull. INCORRECT Gardner-Wells tongs do not require predrilled holes in the skull. The spring-loaded pins are adjusted to the correct depth of penetration. Crutchfield tongs and Vinke tongs require a special instrument that drills into the skull. C) Place the Velcro binders securely around Jonathan's head. INCORRECT Velcro binders are not used in conjunction with Gardner-Wells tongs. D) Apply a halo vest when Jonathan is in the upright position. INCORRECT A halo vest is applied after the tongs are removed. In some instances, the halo vest may be applied while the client is in traction. However, it should never be applied when the client is in an upright position. Points Earned:
0.0/1.0
Correct Answer(s): A
The nursing staff continues to assess Jonathan’s neurological status. The nurse notes that Jonathan's abdomen is slightly distended and bowel sounds are absent on auscultation. The nurse suspects that Jonathan has a paralytic ileus.
9. Which intervention should be implemented for a paralytic ileus? A) Encourage Jonathan to eat a high-calorie, high-fiber diet. INCORRECT The client remains NPO if a paralytic ileus is suspected. B) Turn Jonathan every two hours in the kinetic bed. INCORRECT
Turning the client may address other complications of Spinal Cord Injury (SCI) such as skin integrity or deep vein thrombosis, but it does not address a paralytic ileus. C) Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction. CORRECT A nasogastric tube is inserted to relieve distention and prevent aspiration. D) Continue to assess Jonathan, but take no action at this time. INCORRECT A paralytic ileus is a complication of SCI that requires intervention. Points Earned:
0.0/1.0
Correct Answer(s): C
Because Jonathan needs to remain flat in bed while in traction, the nurse is concerned that he may experience sensory and perceptual problems.
10. Which intervention should the nurse implement to address this concern? A) Do not allow Jonathan to watch television for more than 2 hours at a time. INCORRECT To promote sensory stimulation, the nurse should encourage Jonathan to watch the TV or listen to the radio. B) Encourage Jonathan's girlfriend to be very quiet during visits. INCORRECT The nurse should encourage Jonathan's girlfriend to talk to him and urge him to interact as much as possible. C) Provide Jonathan prism glasses, and tell him how to use them. CORRECT Prism glasses can enable Jonathan to see from the supine position. D) Discuss ways for Jonathan to deal with his depression. INCORRECT Depression is not a sensory or perceptual alteration. It is a psychosocial issue. Points Earned:
1.0/1.0
Correct Answer(s): C
Nursing Diagnosis
The neuro intensive care nurse is developing the nursing care plan for Jonathan.
11. Which nursing diagnosis has priority at this time? A) Self-care deficit. INCORRECT Because Jonathan is in the Neuro-ICU, his needs will be met by the nursing staff. Therefore, this diagnosis is not a priority at this time. B) Disturbed sensory perception. INCORRECT Although motor and sensory impairment are present, they are not the priority nursing diagnosis at this time. C) Risk for impaired skin integrity. CORRECT Immobility always increases the client's risk for impaired skin integrity. Skin sores are the most common and devastating complication of SCI. Maslow's Hierarchy of Needs addresses physiological needs first. D) Risk for ineffective coping. INCORRECT Although Jonathan is at risk for this problem since his entire life has been changed, it is not a priority at this time. Points Earned:
1.0/1.0
Correct Answer(s): C
Evaluating Client Outcomes
The nurse includes the nursing diagnosis, "Risk for impaired skin integrity related to immobility and sensory loss" in Jonathan's plan of care.
12. Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis? A) This client's family inspects the skin for reddened areas daily. INCORRECT While this outcome may be used to evaluate family teaching interventions later in the rehabilitative phase of care. This is not an outcome statement for interventions related to the nursing diagnosis. B) The client exhibits no reddened areas or breaks in the skin. CORRECT This outcome is client-centered and is directly related to the nursing diagnosis.
C) The nursing staff rotates the client's kinetic bed per unit protocol. INCORRECT While this intervention will aid in decreasing the risk of skin breakdown, this is not an outcome statement for the nursing diagnosis. D) The physical therapist performs ive range of motion exercises. INCORRECT While exercise is important to maintain t and muscle integrity, this is not an outcome statement for this diagnosis. Points Earned:
0.0/1.0
Correct Answer(s): B
Ethical Considerations
The night nurse goes into Jonathan's room and finds him crying quietly. The nurse asks him if he would like to talk. Jonathan laments, "Today the doctor told me I will never walk again." He asks the nurse, "Do you think that I will ever be able to walk again?"
13. According to the ethical principle of veracity, how should the nurse respond to Jonathan's question? A) "Are you afraid that you may not be able to walk again?" INCORRECT This is a therapeutic response that helps Jonathan express his feelings, but it is not a response that is based on the ethical principle of veracity. B) "I always believe in hope, Jonathan, so you shouldn't give up." INCORRECT This is not a response that is based on the ethical principle of veracity. C) "No, Jonathan; it is unlikely that you will ever be able to walk again." CORRECT Veracity is the ethical principle that is based on telling the truth. D) "I don't think this is a good time to talk about this. You need to sleep." INCORRECT This is not a response that is based on the ethical principle of veracity. Points Earned:
1.0/1.0
Correct Answer(s): C
One of the night nurses who has been caring for Jonathan since ission has established a therapeutic relationship with him. On numerous occasions, they have had meaningful conversations. Tonight, Jonathan tells the nurse, "I don't want to live if people will have to take care of me. Please tell my family and the doctors that I want to die. I don’t want any medications or treatments. I have already told them, but they won't listen to me."
14. Which intervention should the nurse implement? A) Reassure Jonathan that everything will be all right and encourage him not to think like that. INCORRECT This is false reassurance which does not address Jonathan's concerns. B) Encourage Jonathan to talk to the chaplain about his feelings as soon as possible. INCORRECT Although this intervention might be appropriate, it does not immediately address Jonathan's concerns. C) Request the hospital ethics committee to meet and discuss Jonathan's wishes. INCORRECT This may need to be done at a later time if the family/hospital refuses to honor Jonathan's wishes. D) Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns. CORRECT Client advocacy is a priority for the nurse. Actively advocating for clients that are vulnerable or unable to promote their own needs is the correct ethical action to implement. Additionally, such a meeting can facilitate open communication among all of the parties involved and any misconceptions can be discussed. Points Earned:
1.0/1.0
Correct Answer(s): D
Cultural Considerations
Jonathan's mother comes to the nurse's station and tells the nurse that Jonathan's grandparents have just arrived from Arizona. Jonathan's paternal grandparents live on a Navajo reservation and believe in many old tribal customs. His grandfather is a medicine man who wants to heal Jonathan so that Jonathan can walk again. Jonathan's mother asks if his grandfather can try to heal him.
15. What is the best initial action by the nurse?
A) Explain that the grandfather may visit, but only for ten minutes during visiting hours. INCORRECT This does not address Jonathan's mother's question. B) Discuss the grandfather’s desire with Jonathan, and if he agrees, then allow it. INCORRECT This may be done later, but it is not the best initial action at this time. C) Request an immediate multidisciplinary team meeting to discuss this situation. INCORRECT This may be done later, but it is not the best initial action at this time. D) Obtain more information about what the grandfather wants to do. CORRECT Nursing staff should make an effort to accommodate cultural requests such as this one, while advocating the treatment regimen and protecting the other clients in the ICU. The nurse should obtain more information first, then ask Jonathan if he agrees, then meet with the team to determine the parameters of the grandfather's visit. Points Earned:
1.0/1.0
Correct Answer(s): D
Jonathan's grandfather comes to the nurse's station and requests to talk to someone. He wants to heal his grandson. The charge nurse escorts the grandfather back to the office. The grandfather says, "Jonathan is sick because he does not practice the old ways. He is being punished for this."
16. How should the nurse respond to this statement? A) "Jonathan is a fine young man. He did not do anything wrong. This was just an accident." INCORRECT This is not a culturally sensitive response. B) "Just because he does not believe in your way does not mean he is being punished." INCORRECT This is not a culturally sensitive response. C) Sit quietly and allow the grandfather to continue. CORRECT A person's culture may influence his/her beliefs about the cause of accidents or illness. Clients and families from other cultures may be reluctant to talk to health professionals. Simply listening to them may help them overcome their hesitation. Prior to commenting, the nurse should learn more about what the grandfather would like to do for his grandson. D) Request that the grandfather wait a minute and ask a physician to the meeting. INCORRECT
There is no need for a physician to be in this meeting. Points Earned:
1.0/1.0
Correct Answer(s): C
Jonathan and his grandfather talk. Jonathan agrees to let his grandfather perform a ceremony to strengthen his will, even if his paralysis is not cured.
Legal Issues
Jonathan tells the nurse, "Someone said I should have a living will. Can you tell me what that is?"
17. How should the nurse respond? A) "You want to know about a living will? Are you thinking about hurting yourself?" INCORRECT Jonathan is merely asking a question. The nurse should provide factual information to answer his question. B) "I will call the chaplain so he can discuss the living will with you." INCORRECT The nurse can answer the question. There is no need to refer Jonathan to a chaplain. C) "It is a legal document that helps us make decisions about your healthcare, based on your wishes." CORRECT A living will is an advance directive that documents a person's wishes concerning treatment when those wishes can no longer be communicated. D) "You must appoint someone to make decisions about your treatment if you are unable to do so." INCORRECT This is an explanation of a durable power of attorney for health care, not a living will. Points Earned:
1.0/1.0
Correct Answer(s): C
The young man who hit Jonathan in the football game comes to the nurse’s station and asks to see him. He questions the nurse. "How is Jonathan doing? Will he ever walk again?"
18. What is the best response by the nurse? A) "He is doing better, but he will never be able to walk again." INCORRECT This violates the Health Insurance Portability and ability Act (HIPAA) policies concerning confidentiality. B) "I am sorry, but I cannot share that information with you." CORRECT HIPAA mandates that the nurse protect the client's personal health information unless given permission by the client to disclose it. C) "Jonathan is in his room, but I don’t think you should visit him." INCORRECT Not only does the nurse fail to address the young man's questions, the nurse has no right to decide who can visit Jonathan. D) "I think his mother is in the waiting room. Let me ask her if I can speak with you about Jonathan." INCORRECT As an adult, it is Jonathan's decision, not his mother's, to decide if information may be shared. Points Earned:
1.0/1.0
Correct Answer(s): B
Psychosocial Nursing Interventions
Jonathan is a very quiet young man. He complies with the nurses' requests, never complains about anything, and answers questions when he is asked. His mother, girlfriend, and grandparents have been visiting him daily in the ICU. He will not talk to them except to respond to their questions with a yes or no answer. The nurse learns that Jonathan has two brothers who live in another state and that their father died ten years ago in the line of duty as a fireman.
19. Which psychosocial intervention by the nurse has priority at this time? A) Talk to Jonathan's mother about his previous coping skills. INCORRECT This may be done, but it is not a priority at this time. B) Let Jonathan know that if he wants to talk or has questions, the nurse is available to listen. CORRECT This action gives Jonathan the option to talk more about his feelings without forcing him to do so.
C) Notify the healthcare provider to obtain a psychiatric consultation. INCORRECT This may be needed after further evaluation, but is not a priority at this time. D) Ask Jonathan's mother, girlfriend, and grandparents to limit visits because they seem to cause added stress. INCORRECT Jonathan has not indicated that his family is a stressor, and their continued presence and may encourage Jonathan to verbalize his feelings. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is walking by the Neuro-ICU waiting room and notices Jonathan's mother sitting and crying. There is no one else in the waiting room.
20. Which action should the nurse implement at this time? A) Allow Jonathan's mother to cry and do not disturb her. INCORRECT Jonathan's mother is alone. Her husband is dead, and her other sons live out of state. An intervention by the nurse is indicated. B) Ask the hospital chaplain to come and see Jonathan's mother. INCORRECT This may be done later, but it is not the best action at this time. C) Sit down beside Jonathan's mother. CORRECT Offering a caring, ive presence to Jonathan's mother is the priority intervention at this time. It provides an opportunity for Jonathan’s mother to share her feelings, if she desires to do so. D) Discuss this situation with Jonathan as soon as possible. INCORRECT Jonathan does not need to know that his mother is crying. It should be Jonathan's mother's decision to share her feelings with him. Points Earned:
1.0/1.0
Correct Answer(s): C
Transfer to the Rehabilitation Unit
After ten days in the neuro intensive care unit and two weeks in the neuro unit, Jonathan is transferred to the rehabilitation unit. His cervical spine remains in alignment through the use of a halo vest, but he is a quadriplegic at the C8 level. He now has some movement in his hands, but he is still unable to move his arms and legs. Jonathan is able to sit upright in a wheelchair and has advanced to a regular diet. Because Jonathan has a reflexic bowel, a bowel program is instituted so that he can have bowel movements.
21. Which information should the nurse include when discussing a bowel elimination program with Jonathan? A) Explain the importance of drinking cold fluids prior to defecation. INCORRECT Warm fluids, like coffee or tea can help to promote the gastrocolic reflex. This stimulates peristalsis, forcing stool toward the rectum. B) Plan bowel evacuation at the same time every day. CORRECT Bowel care is best when scheduled at the same time every day in order to develop a habitual response. C) The importance of turning to his right side. INCORRECT Placing the client on the left side, rather than the right side, allows gravity to help move the stool into the rectum. D) Daily enemas will be needed to help achieve a bowel movement. INCORRECT Daily enemas are not a part of the program for reflexic bowel. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is discussing autonomic dysreflexia with Jonathan, his girlfriend, and his mother. To evaluate the teaching, the nurse asks Jonathan to explain what it means.
22. Which statement by Jonathan indicates an understanding of autonomic dysreflexia? A) "If I start feeling lightheaded when I get up, I should raise my head more slowly." INCORRECT Lightheadedness is a symptom of orthostatic hypotension. B) "I should empty my bladder at least every two to three hours." CORRECT
Autonomic dysreflexia most often occurs as a result of an overfull bladder, although it can be brought on by other noxious stimuli. It can develop suddenly, and if it is not treated promptly, it can lead to seizures, stroke, and death. Therefore, prevention is very important. C) "It is a complication that occurs if my extremities aren't moved every two hours." INCORRECT This is an explanation of a pressure ulcer. D) "It's an automatic response that occurs whenever I have a bowel movement." INCORRECT It does not occur with a bowel movement. Constipation is the second most common cause of autonomic dysreflexia. Points Earned:
0.0/1.0
Correct Answer(s): B
During the night shift, Jonathan calls the nursing desk and says, "I have a pounding headache; please give me something." The nurse goes to Jonathan's room.
23. Which intervention should the nurse implement first? A) Assess Jonathan's bladder for distention. INCORRECT This may be the cause of the headache, but it is not the intervention that should be done first. B) Move Jonathan to a sitting position. CORRECT The client may be experiencing autonomic dysreflexia, an exaggerated autonomic response to a noxious stimulus resulting in hypertension and a pounding headache. Putting Jonathan in a sitting position helps lower the blood pressure. The nurse can then assess for the stimulus and ister medications if needed. C) ister a ganglionic blocking agent IVP. INCORRECT If other measures do not relieve the hypertension, this type of medication may be given. However, it is not the priority intervention. D) Attempt to determine what triggered the headache. INCORRECT The headache may be a symptom of autonomic dysreflexia, so the trigger needs to be determined and alleviated immediately. However, another intervention should be taken first. Points Earned:
1.0/1.0
Correct Answer(s): B
Because of his paralysis, Jonathan is at risk for disuse syndrome.
24. Which intervention should the nurse implement to address disuse syndrome? A) Perform ive range of motion (ROM) exercises every 4 hours. CORRECT Jonathan is at risk for developing contractures as a result of disuse syndrome (atrophy due to loss of motor and sensory functions below the level of the injury). Performing ROM exercises every four hours will help prevent disuse syndrome. B) Encourage Jonathan to avoid stretching his Achilles tendon. INCORRECT The Achilles tendon should be stretched and exercised to prevent foot drop. C) Discuss methods to promote regular mental stimulation. INCORRECT While promoting mental stimulation may be helpful to Jonathan, it does not address the disuse syndrome brought about by SCI. D) Assess the skin for any reddened areas at least every shift. INCORRECT This addresses Jonathan's risk for skin breakdown, but it does not address disuse syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Management Considerations
Jonathan's rehabilitation nurse, an unlicensed assistive personnel (UAP), and an aide are caring for six clients on the unit.
25. Which task should the nurse delegate to the UAP? A) Teach Jonathan how to use the electric wheelchair. INCORRECT Client teaching requires the professional expertise of the nurse. It should not be assigned to the UAP. B) Assess Jonathan's ability to perform activities of daily living. INCORRECT The nurse cannot delegate any type of assessment to the UAP.
C) Measure the intake and output (I&0) for the client taking diuretics. CORRECT The UAP can obtain the I&O measurements, but any assessments about the effectiveness of diuretics remain the responsibility of the nurse. D) Discuss appropriate ways to prevent urinary tract infections. INCORRECT Client teaching requires the professional expertise of the nurse. It should not be assigned to the UAP. Points Earned:
1.0/1.0
Correct Answer(s): C
The rehabilitation nurse is observing the unlicensed assistive personnel (UAP) caring for a paraplegic client on the unit.
26. Which behavior by the UAP warrants immediate intervention by the nurse? A) The UAP is feeding the client. CORRECT The client is a paraplegic, so has the use of upper extremities. During the rehabilitation phase of care, independence must be encouraged, so the client should not be fed. B) The UAP is taking a tympanic temperature. INCORRECT Taking a tympanic temperature is a nursing task the UAP can perform. C) The UAP is emptying the Foley catheter bag. INCORRECT Emptying a Foley catheter bag is a nursing task the UAP can perform. D) The UAP is placing socks on the client's feet. INCORRECT Placing socks on the client's feet is a nursing task the UAP can perform. Points Earned:
1.0/1.0
Correct Answer(s): A
Preparing for Discharge
Jonathan tells the nurse, "I am afraid my girlfriend will leave me, but I can't blame her for leaving someone who can't even hold her hand."
27. Which intervention should the nurse implement first? A) Encourage Jonathan to talk to his girlfriend about his concerns. INCORRECT This may be implemented at a later date, but it is not the priority intervention. B) Refer Jonathan and his girlfriend to a counselor for sexual education. INCORRECT This should be done, but it is not the priority intervention. C) Ask Jonathan if he would like to share his fears about life after leaving the hospital. CORRECT The nurse should first directly address Jonathan's fears and concerns, then encourage Jonathan to talk with his girlfriend. Referral for sexual counseling and a team meeting can be initiated at a later time. D) Request a meeting with Jonathan's healthcare team. INCORRECT Although this may be needed, it is not a priority intervention at this time. Points Earned:
0.0/1.0
Correct Answer(s): C
Jonathan voices concern about how he will be able to make a living after being released from the rehabilitation unit. Prior to the accident he worked at a local factory and attended a community college. His goal was to become a fireman, like his father.
28. Which action should the nurse implement? A) Refer Jonathan to a local counselor for vocational rehabilitation. CORRECT Vocational rehabilitation counselors assist clients with disabilities in planning careers and finding jobs. Jonathan is only 22 years old, and he needs to be productive. B) Discuss the Americans with Disabilities Act with Jonathan and his mother. INCORRECT This is a bill enacted by Congress that prohibits employers from discriminating against qualified individuals with disabilities. C) Suggest that Jonathan apply for disability payments and not worry about working. INCORRECT While Jonathan may be eligible for disability payments, this action does not address his concerns or desires to make a living after he leaves the unit.
D) Reassure Jonathan that everything will be all right after he goes home. INCORRECT This is false reassurance and does not address Jonathan's concern about how he will make a living after he leaves the unit. Points Earned:
0.0/1.0
Correct Answer(s): A
Jonathan is being discharged to his mother's home. His mother and his girlfriend will work together to provide care for Jonathan. The nurse is teaching Jonathan, his mother, and his girlfriend about muscle spasticity, one of the most common complications of quadriplegia.
29. Which intervention will the nurse include when discussing ways to prevent muscle spasticity? A) Encourage Jonathan to use a footboard at all times. INCORRECT Footboards help prevent foot drop, a contracture that may occur due to disuse syndrome. It is not useful for control of muscle spasticity. B) Perform stretching exercises five to seven times each day. CORRECT Stretching exercises are an effective, non-invasive treatment for spasticity. The stretches should be held for 45 to 90 seconds. They must be done 5 to 7 times per day because the effect on spasticity generally lasts for only a few hours. C) Instruct Jonathan to lay in the prone position 2 hours daily. INCORRECT Lying prone may help prevent skin breakdown, but it will not directly control muscle spasticity. D) Take the prescribed antibiotic when the spasms occur. INCORRECT Antispasmodic mediations may be prescribed, but antibiotics are not used to treat muscle spasms. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is discussing bladder management with Jonathan and his mother. Jonathan has a spastic (reflexic) bladder and has been wearing a condom catheter.
30. Which statement by Jonathan's mother indicates that she has an understanding of the bladder care plan designed for Jonathan?
A) "I will limit Jonathan's fluid intake so the drainage bag won't fill so quickly." INCORRECT Adequate fluid intake (2 to 3 liters per day) is necessary to promote adequate urinary output and promote hydration. B) "I should remove the condom catheter nightly to clean his penis." CORRECT Warm urine on the periurethral skin promotes bacterial growth and colonization. The condom catheter should be removed and the skin cleaned and inspected daily. C) "Once the condom catheter is applied, I do not need to check it." INCORRECT The catheter should be inspected an hour after application to ensure that it is not too tight, which would cut off circulation to the penis. D) "If the catheter is draining slowly, I should immediately catheterize Jonathan to empty the bladder." INCORRECT Jonathan's mother should first check the tubing for kinking and then review fluid intake for the day before immediately catheterizing Jonathan. She can also be taught to palpate for bladder distention. Points Earned:
1.0/1.0
Correct Answer(s): B
Multidisciplinary Team Meeting
The multidisciplinary team is meeting to discuss discharge for Jonathan. The team is concerned that Jonathan's mother and girlfriend will not be able to care for him in the mother's home. The team are not sure that the mother's home is equipped and disability ready for Jonathan.
31. Which member of the rehabilitation multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped to care for him? A) The recreational therapist. INCORRECT This team member works to help clients continue, or develop hobbies or interests, and often works with the occupational therapist. B) The physiatrist. INCORRECT This team member is a physician who specializes in rehabilitative medicine.
C) The occupational therapist. CORRECT This team member works to develop the client's fine motor skills used for activities of daily living, and will do a home evaluation to determine what must be done so that Jonathan can function in the home as independently as possible. D) The cognitive therapist. INCORRECT This individual works primarily with clients who have experienced head injuries and have cognitive impairments. Points Earned:
1.0/1.0
Correct Answer(s): C
The of the healthcare team are evaluating the discharge teaching that Jonathan and his significant others received while in the rehabilitation unit.
32. Which area has priority according to Maslow's Hierarchy of Needs? A) Evaluation of Jonathan's ability to transfer from bed to chair. INCORRECT Safety is important but it is not the top priority. B) Instructions concerning ways to prevent urinary tract infections. CORRECT Jonathan is at risk for urinary tract infection, a common complication of a reflexic bladder. Based on Maslow's Hierarchy of Needs, physiological needs are of the highest priority. C) Issues addressing Jonathan's potential for vocational training. INCORRECT Esteem and recognition are important, but not the highest priority. D) Assurance that significant others have resources available, if needed. INCORRECT This is important, but is not the highest priority. Points Earned:
0.0/1.0
Correct Answer(s): B
Case Outcome
The house is evaluated, and with a few minor changes, it is determined that Jonathan can go to his mother's home to live. The house has been equipped with a ramp, and what was once the
dining room will now be Jonathan’s bedroom. Home health services is scheduled to visit Jonathan daily. His significant others have verbalized and accurately demonstrated the care he will need when he is discharged home. Jonathan's mother and girlfriend are excited about his discharge and think they are ready for the challenge. Tomorrow is the big day when Jonathan will be starting his new life outside the hospital as a quadriplegic. With his family's , the efforts of his healthcare team, and his strong spirit, it should be possible for Jonathan to lead a satisfying and productive life.
All of Jonathan's friends are standing around him, unsure about what to do. They are afraid that he is badly hurt. Jonathan thinks it is just a temporary sting and states that he will be all right in a few minutes. One of the men calls 911 on a cell phone.
1. What should Jonathan's friends do while waiting for emergency personnel to arrive? A) Help Jonathan move his legs and assist him to sit up. INCORRECT No one should help Jonathan move his legs or assist him. B) Place a blanket over Jonathan and make sure no one moves him. CORRECT Any movement or improper handling could cause further damage and loss of neurological function. C) Attempt to stabilize his neck with any type of soft material. INCORRECT Any attempt to manipulate the neck could cause further damage and loss of neurological function. D) Carefully put Jonathan in the back of a truck with one man holding his neck. INCORRECT Any action that manipulates the neck could cause further damage and loss of neurological function. Points Earned:
0.0/1.0
Correct Answer(s): B
An ambulance arrives within a few minutes. Two paramedics and an Emergency Department (ED) nurse on a "ride-along" quickly take control of the situation. The nurse assists the paramedics as they prepare Jonathan for transport to the trauma center.
2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further? A) Logroll to side while maintaining neutral alignment. INCORRECT This action would be used to move an injured person from a prone position to supine if respiratory compromise occurs. It is not the best way to open the airway of a person who is already in the supine position.
B) Perform the jaw-thrust technique. CORRECT The jaw-thrust is the safest first approach to opening the airway of a casualty who has a suspected neck injury because in most cases it can be accomplished without extending the neck. C) Flex the neck with a wedge pillow. INCORRECT This action could cause further damage to the spinal cord as it stretches the back of the neck. D) Use the chin-lift/head tilt technique. INCORRECT This technique causes extension of the neck and could cause further damage. Points Earned:
1.0/1.0
Correct Answer(s): B
Keeping the head, neck, and spinal column in a neutral position, the paramedics and the nurse apply a cervical collar and place Jonathan on a scoop stretcher. A large bore IV is started and oxygen is applied at 8 liters/minute using nasal prongs. Jonathan is transported to the trauma center via ambulance.
Clinical Manifestations
When Jonathan is itted to the emergency department, the trauma nurse performs a neurological assessment.
3. Which intervention has highest priority when assessing Jonathan? A) Palpate the lower abdomen for any signs of urinary retention. INCORRECT Although urinary retention is assessed to help diagnose spinal shock, it does not have the highest priority. B) Assess sensation by gently pinching the skin distal to proximal. INCORRECT Although sensation is evaluated in this manner, this assessment does not have the highest priority. C) Assess Jonathan's breathing pattern and his ability to cough. CORRECT
Since a cervical spinal cord injury is suspected, the nurse must be aware that edema may ascend the spinal cord, which can compromise breathing and coughing. Breathing is always the priority, especially when there is the possibility that oxygenation might be impaired. D) Monitor the client's vital signs, especially a tympanic temperature. INCORRECT An autonomic disruption may cause an alteration in temperature, but this assessment does not have the highest priority. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse completes the ission assessment and documents the findings in the nurse’s notes.
4. Which assessment data warrants immediate intervention by the emergency room nurse? A) Jonathan has a slight sensation in his right metatarsals. INCORRECT The return of sensation in his toes is an excellent outcome that does not warrant any intervention. B) Jonathan's respirations are 20 and unlabored. INCORRECT Because the client's respirations are within normal limits for an adult, no intervention is needed. C) Jonathan's blood pressure is 96/60, and his pulse is 48. CORRECT Hypotension and bradycardia are signs of neurogenic shock. This is a medical emergency that warrants immediate intervention. D) Jonathan is complaining of a headache. INCORRECT Although Jonathan's headache may be due to his fall, further assessment is needed prior to intervening. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse recognizes that Jonathan is experiencing spinal shock.
5. Which intervention should the nurse implement first?
A) Assess Jonathan for symptoms of a paralytic ileus. INCORRECT Although a paralytic ileus can occur, it is not the priority intervention. B) Notify the emergency room physician immediately. CORRECT This is a medical emergency. Spinal shock is the complete loss of all reflex, motor, sensory, and autonomic activity below the lesion. It is imperative to reverse spinal shock as quickly as possible. C) Assist the physician to insert an endotracheal tube. INCORRECT Jonathan may need to be put on a mechanical ventilator, which would require the insertion of an endotracheal tube, but it is not the priority intervention. D) Prepare to ister the vasoconstrictor, dopamine. INCORRECT This may be necessary but this is not the first intervention. Points Earned:
1.0/1.0
Correct Answer(s): B
The trauma physician and ER team work to stabilize Jonathan's condition. The trauma team inserts a central venous catheter and a Foley catheter with a urimeter attached. When Jonathan's hemodynamic status improves, he is sent for a STAT Computer Tomography (CT) scan.
Continued Stabilization in the Emergency Department
The trauma physician writes the initial prescriptions for treatment.
6. Which medication should the emergency room nurse expect the physician to prescribe for Jonathan? A) Morphine, an opioid analgesic. INCORRECT Other than a headache, there is no data to indicate Jonathan is in pain. B) Mannitol (Osmitrol), an osmotic diuretic. INCORRECT This medication is used to treat increased intracranial pressure in a head injury. There is currently no data to a brain injury.
C) Methylprednisolone Sodium Succinate (Solu-Medrol), a corticosteroid. CORRECT This medication, when given within eight hours of injury, decreases inflammation, thereby reducing damage to cell membranes. D) Acetylsalicylic acid (aspirin), a nonsteroidal antiinflammatory drug. INCORRECT NSAID’s are not a treatment of choice for an SCI. Points Earned:
1.0/1.0
Correct Answer(s): C
The medication is prescribed as 125 mg IVPB over 30 minutes. The intravenous piggy back (IVPB) containing the medication contains 100 ml of fluid. The drop factor on the IV tubing is 10 gtts/ml.
7. How many drops per minute (gtts/min) should the nurse regulate the IVPB? A) 33 gtts/min. CORRECT Amount infused (100 ml) multiplied by drop factor (10) divided by minutes to infuse (30) equals 33 gtts/min. B) 50 gtts/min. INCORRECT the formula for calculating an IV flow rate. C) 100 gtts/min. INCORRECT the formula for calculating an IV flow rate. D) 125 gtts/min. INCORRECT the formula for calculating an IV flow rate. Points Earned:
1.0/1.0
Correct Answer(s): A
Nursing Interventions in the Neuro Intensive Care Unit
Jonathan is itted to the Neuro Intensive Care Unit. His cervical spine is stabilized with Gardner-Wells tongs, a Foley catheter is inserted, and he is placed on a kinetic bed. Jonathan is
alert and oriented and denies any pain or discomfort at this time. He is still unable to move any of his upper or lower extremities, and he has sensory deficits from the chest area down.
8. Which nursing intervention is included in the care plan when managing a client with GardnerWells tongs? A) Do not remove the traction weights and ensure they hang freely. CORRECT Traction is applied to the tongs by employing weights to maintain alignment. Removing the weights would result in misalignment, possibly creating further damage. Weights should hang freely so they do not interfere with the traction. Jonathan should also be assessed for evidence of infection at the spring-loaded pin sites. B) Ensure that an extra set of drill bits are available in case a new set of predrilled holes must be made in Jonathan's skull. INCORRECT Gardner-Wells tongs do not require predrilled holes in the skull. The spring-loaded pins are adjusted to the correct depth of penetration. Crutchfield tongs and Vinke tongs require a special instrument that drills into the skull. C) Place the Velcro binders securely around Jonathan's head. INCORRECT Velcro binders are not used in conjunction with Gardner-Wells tongs. D) Apply a halo vest when Jonathan is in the upright position. INCORRECT A halo vest is applied after the tongs are removed. In some instances, the halo vest may be applied while the client is in traction. However, it should never be applied when the client is in an upright position. Points Earned:
0.0/1.0
Correct Answer(s): A
The nursing staff continues to assess Jonathan’s neurological status. The nurse notes that Jonathan's abdomen is slightly distended and bowel sounds are absent on auscultation. The nurse suspects that Jonathan has a paralytic ileus.
9. Which intervention should be implemented for a paralytic ileus? A) Encourage Jonathan to eat a high-calorie, high-fiber diet. INCORRECT The client remains NPO if a paralytic ileus is suspected. B) Turn Jonathan every two hours in the kinetic bed. INCORRECT
Turning the client may address other complications of Spinal Cord Injury (SCI) such as skin integrity or deep vein thrombosis, but it does not address a paralytic ileus. C) Insert a nasogastric tube and set the siphon drainage to a low, intermittent suction. CORRECT A nasogastric tube is inserted to relieve distention and prevent aspiration. D) Continue to assess Jonathan, but take no action at this time. INCORRECT A paralytic ileus is a complication of SCI that requires intervention. Points Earned:
0.0/1.0
Correct Answer(s): C
Because Jonathan needs to remain flat in bed while in traction, the nurse is concerned that he may experience sensory and perceptual problems.
10. Which intervention should the nurse implement to address this concern? A) Do not allow Jonathan to watch television for more than 2 hours at a time. INCORRECT To promote sensory stimulation, the nurse should encourage Jonathan to watch the TV or listen to the radio. B) Encourage Jonathan's girlfriend to be very quiet during visits. INCORRECT The nurse should encourage Jonathan's girlfriend to talk to him and urge him to interact as much as possible. C) Provide Jonathan prism glasses, and tell him how to use them. CORRECT Prism glasses can enable Jonathan to see from the supine position. D) Discuss ways for Jonathan to deal with his depression. INCORRECT Depression is not a sensory or perceptual alteration. It is a psychosocial issue. Points Earned:
1.0/1.0
Correct Answer(s): C
Nursing Diagnosis
The neuro intensive care nurse is developing the nursing care plan for Jonathan.
11. Which nursing diagnosis has priority at this time? A) Self-care deficit. INCORRECT Because Jonathan is in the Neuro-ICU, his needs will be met by the nursing staff. Therefore, this diagnosis is not a priority at this time. B) Disturbed sensory perception. INCORRECT Although motor and sensory impairment are present, they are not the priority nursing diagnosis at this time. C) Risk for impaired skin integrity. CORRECT Immobility always increases the client's risk for impaired skin integrity. Skin sores are the most common and devastating complication of SCI. Maslow's Hierarchy of Needs addresses physiological needs first. D) Risk for ineffective coping. INCORRECT Although Jonathan is at risk for this problem since his entire life has been changed, it is not a priority at this time. Points Earned:
1.0/1.0
Correct Answer(s): C
Evaluating Client Outcomes
The nurse includes the nursing diagnosis, "Risk for impaired skin integrity related to immobility and sensory loss" in Jonathan's plan of care.
12. Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis? A) This client's family inspects the skin for reddened areas daily. INCORRECT While this outcome may be used to evaluate family teaching interventions later in the rehabilitative phase of care. This is not an outcome statement for interventions related to the nursing diagnosis. B) The client exhibits no reddened areas or breaks in the skin. CORRECT This outcome is client-centered and is directly related to the nursing diagnosis.
C) The nursing staff rotates the client's kinetic bed per unit protocol. INCORRECT While this intervention will aid in decreasing the risk of skin breakdown, this is not an outcome statement for the nursing diagnosis. D) The physical therapist performs ive range of motion exercises. INCORRECT While exercise is important to maintain t and muscle integrity, this is not an outcome statement for this diagnosis. Points Earned:
0.0/1.0
Correct Answer(s): B
Ethical Considerations
The night nurse goes into Jonathan's room and finds him crying quietly. The nurse asks him if he would like to talk. Jonathan laments, "Today the doctor told me I will never walk again." He asks the nurse, "Do you think that I will ever be able to walk again?"
13. According to the ethical principle of veracity, how should the nurse respond to Jonathan's question? A) "Are you afraid that you may not be able to walk again?" INCORRECT This is a therapeutic response that helps Jonathan express his feelings, but it is not a response that is based on the ethical principle of veracity. B) "I always believe in hope, Jonathan, so you shouldn't give up." INCORRECT This is not a response that is based on the ethical principle of veracity. C) "No, Jonathan; it is unlikely that you will ever be able to walk again." CORRECT Veracity is the ethical principle that is based on telling the truth. D) "I don't think this is a good time to talk about this. You need to sleep." INCORRECT This is not a response that is based on the ethical principle of veracity. Points Earned:
1.0/1.0
Correct Answer(s): C
One of the night nurses who has been caring for Jonathan since ission has established a therapeutic relationship with him. On numerous occasions, they have had meaningful conversations. Tonight, Jonathan tells the nurse, "I don't want to live if people will have to take care of me. Please tell my family and the doctors that I want to die. I don’t want any medications or treatments. I have already told them, but they won't listen to me."
14. Which intervention should the nurse implement? A) Reassure Jonathan that everything will be all right and encourage him not to think like that. INCORRECT This is false reassurance which does not address Jonathan's concerns. B) Encourage Jonathan to talk to the chaplain about his feelings as soon as possible. INCORRECT Although this intervention might be appropriate, it does not immediately address Jonathan's concerns. C) Request the hospital ethics committee to meet and discuss Jonathan's wishes. INCORRECT This may need to be done at a later time if the family/hospital refuses to honor Jonathan's wishes. D) Arrange a meeting with Jonathan, his family, and the healthcare team to discuss Jonathan's concerns. CORRECT Client advocacy is a priority for the nurse. Actively advocating for clients that are vulnerable or unable to promote their own needs is the correct ethical action to implement. Additionally, such a meeting can facilitate open communication among all of the parties involved and any misconceptions can be discussed. Points Earned:
1.0/1.0
Correct Answer(s): D
Cultural Considerations
Jonathan's mother comes to the nurse's station and tells the nurse that Jonathan's grandparents have just arrived from Arizona. Jonathan's paternal grandparents live on a Navajo reservation and believe in many old tribal customs. His grandfather is a medicine man who wants to heal Jonathan so that Jonathan can walk again. Jonathan's mother asks if his grandfather can try to heal him.
15. What is the best initial action by the nurse?
A) Explain that the grandfather may visit, but only for ten minutes during visiting hours. INCORRECT This does not address Jonathan's mother's question. B) Discuss the grandfather’s desire with Jonathan, and if he agrees, then allow it. INCORRECT This may be done later, but it is not the best initial action at this time. C) Request an immediate multidisciplinary team meeting to discuss this situation. INCORRECT This may be done later, but it is not the best initial action at this time. D) Obtain more information about what the grandfather wants to do. CORRECT Nursing staff should make an effort to accommodate cultural requests such as this one, while advocating the treatment regimen and protecting the other clients in the ICU. The nurse should obtain more information first, then ask Jonathan if he agrees, then meet with the team to determine the parameters of the grandfather's visit. Points Earned:
1.0/1.0
Correct Answer(s): D
Jonathan's grandfather comes to the nurse's station and requests to talk to someone. He wants to heal his grandson. The charge nurse escorts the grandfather back to the office. The grandfather says, "Jonathan is sick because he does not practice the old ways. He is being punished for this."
16. How should the nurse respond to this statement? A) "Jonathan is a fine young man. He did not do anything wrong. This was just an accident." INCORRECT This is not a culturally sensitive response. B) "Just because he does not believe in your way does not mean he is being punished." INCORRECT This is not a culturally sensitive response. C) Sit quietly and allow the grandfather to continue. CORRECT A person's culture may influence his/her beliefs about the cause of accidents or illness. Clients and families from other cultures may be reluctant to talk to health professionals. Simply listening to them may help them overcome their hesitation. Prior to commenting, the nurse should learn more about what the grandfather would like to do for his grandson. D) Request that the grandfather wait a minute and ask a physician to the meeting. INCORRECT
There is no need for a physician to be in this meeting. Points Earned:
1.0/1.0
Correct Answer(s): C
Jonathan and his grandfather talk. Jonathan agrees to let his grandfather perform a ceremony to strengthen his will, even if his paralysis is not cured.
Legal Issues
Jonathan tells the nurse, "Someone said I should have a living will. Can you tell me what that is?"
17. How should the nurse respond? A) "You want to know about a living will? Are you thinking about hurting yourself?" INCORRECT Jonathan is merely asking a question. The nurse should provide factual information to answer his question. B) "I will call the chaplain so he can discuss the living will with you." INCORRECT The nurse can answer the question. There is no need to refer Jonathan to a chaplain. C) "It is a legal document that helps us make decisions about your healthcare, based on your wishes." CORRECT A living will is an advance directive that documents a person's wishes concerning treatment when those wishes can no longer be communicated. D) "You must appoint someone to make decisions about your treatment if you are unable to do so." INCORRECT This is an explanation of a durable power of attorney for health care, not a living will. Points Earned:
1.0/1.0
Correct Answer(s): C
The young man who hit Jonathan in the football game comes to the nurse’s station and asks to see him. He questions the nurse. "How is Jonathan doing? Will he ever walk again?"
18. What is the best response by the nurse? A) "He is doing better, but he will never be able to walk again." INCORRECT This violates the Health Insurance Portability and ability Act (HIPAA) policies concerning confidentiality. B) "I am sorry, but I cannot share that information with you." CORRECT HIPAA mandates that the nurse protect the client's personal health information unless given permission by the client to disclose it. C) "Jonathan is in his room, but I don’t think you should visit him." INCORRECT Not only does the nurse fail to address the young man's questions, the nurse has no right to decide who can visit Jonathan. D) "I think his mother is in the waiting room. Let me ask her if I can speak with you about Jonathan." INCORRECT As an adult, it is Jonathan's decision, not his mother's, to decide if information may be shared. Points Earned:
1.0/1.0
Correct Answer(s): B
Psychosocial Nursing Interventions
Jonathan is a very quiet young man. He complies with the nurses' requests, never complains about anything, and answers questions when he is asked. His mother, girlfriend, and grandparents have been visiting him daily in the ICU. He will not talk to them except to respond to their questions with a yes or no answer. The nurse learns that Jonathan has two brothers who live in another state and that their father died ten years ago in the line of duty as a fireman.
19. Which psychosocial intervention by the nurse has priority at this time? A) Talk to Jonathan's mother about his previous coping skills. INCORRECT This may be done, but it is not a priority at this time. B) Let Jonathan know that if he wants to talk or has questions, the nurse is available to listen. CORRECT This action gives Jonathan the option to talk more about his feelings without forcing him to do so.
C) Notify the healthcare provider to obtain a psychiatric consultation. INCORRECT This may be needed after further evaluation, but is not a priority at this time. D) Ask Jonathan's mother, girlfriend, and grandparents to limit visits because they seem to cause added stress. INCORRECT Jonathan has not indicated that his family is a stressor, and their continued presence and may encourage Jonathan to verbalize his feelings. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is walking by the Neuro-ICU waiting room and notices Jonathan's mother sitting and crying. There is no one else in the waiting room.
20. Which action should the nurse implement at this time? A) Allow Jonathan's mother to cry and do not disturb her. INCORRECT Jonathan's mother is alone. Her husband is dead, and her other sons live out of state. An intervention by the nurse is indicated. B) Ask the hospital chaplain to come and see Jonathan's mother. INCORRECT This may be done later, but it is not the best action at this time. C) Sit down beside Jonathan's mother. CORRECT Offering a caring, ive presence to Jonathan's mother is the priority intervention at this time. It provides an opportunity for Jonathan’s mother to share her feelings, if she desires to do so. D) Discuss this situation with Jonathan as soon as possible. INCORRECT Jonathan does not need to know that his mother is crying. It should be Jonathan's mother's decision to share her feelings with him. Points Earned:
1.0/1.0
Correct Answer(s): C
Transfer to the Rehabilitation Unit
After ten days in the neuro intensive care unit and two weeks in the neuro unit, Jonathan is transferred to the rehabilitation unit. His cervical spine remains in alignment through the use of a halo vest, but he is a quadriplegic at the C8 level. He now has some movement in his hands, but he is still unable to move his arms and legs. Jonathan is able to sit upright in a wheelchair and has advanced to a regular diet. Because Jonathan has a reflexic bowel, a bowel program is instituted so that he can have bowel movements.
21. Which information should the nurse include when discussing a bowel elimination program with Jonathan? A) Explain the importance of drinking cold fluids prior to defecation. INCORRECT Warm fluids, like coffee or tea can help to promote the gastrocolic reflex. This stimulates peristalsis, forcing stool toward the rectum. B) Plan bowel evacuation at the same time every day. CORRECT Bowel care is best when scheduled at the same time every day in order to develop a habitual response. C) The importance of turning to his right side. INCORRECT Placing the client on the left side, rather than the right side, allows gravity to help move the stool into the rectum. D) Daily enemas will be needed to help achieve a bowel movement. INCORRECT Daily enemas are not a part of the program for reflexic bowel. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is discussing autonomic dysreflexia with Jonathan, his girlfriend, and his mother. To evaluate the teaching, the nurse asks Jonathan to explain what it means.
22. Which statement by Jonathan indicates an understanding of autonomic dysreflexia? A) "If I start feeling lightheaded when I get up, I should raise my head more slowly." INCORRECT Lightheadedness is a symptom of orthostatic hypotension. B) "I should empty my bladder at least every two to three hours." CORRECT
Autonomic dysreflexia most often occurs as a result of an overfull bladder, although it can be brought on by other noxious stimuli. It can develop suddenly, and if it is not treated promptly, it can lead to seizures, stroke, and death. Therefore, prevention is very important. C) "It is a complication that occurs if my extremities aren't moved every two hours." INCORRECT This is an explanation of a pressure ulcer. D) "It's an automatic response that occurs whenever I have a bowel movement." INCORRECT It does not occur with a bowel movement. Constipation is the second most common cause of autonomic dysreflexia. Points Earned:
0.0/1.0
Correct Answer(s): B
During the night shift, Jonathan calls the nursing desk and says, "I have a pounding headache; please give me something." The nurse goes to Jonathan's room.
23. Which intervention should the nurse implement first? A) Assess Jonathan's bladder for distention. INCORRECT This may be the cause of the headache, but it is not the intervention that should be done first. B) Move Jonathan to a sitting position. CORRECT The client may be experiencing autonomic dysreflexia, an exaggerated autonomic response to a noxious stimulus resulting in hypertension and a pounding headache. Putting Jonathan in a sitting position helps lower the blood pressure. The nurse can then assess for the stimulus and ister medications if needed. C) ister a ganglionic blocking agent IVP. INCORRECT If other measures do not relieve the hypertension, this type of medication may be given. However, it is not the priority intervention. D) Attempt to determine what triggered the headache. INCORRECT The headache may be a symptom of autonomic dysreflexia, so the trigger needs to be determined and alleviated immediately. However, another intervention should be taken first. Points Earned:
1.0/1.0
Correct Answer(s): B
Because of his paralysis, Jonathan is at risk for disuse syndrome.
24. Which intervention should the nurse implement to address disuse syndrome? A) Perform ive range of motion (ROM) exercises every 4 hours. CORRECT Jonathan is at risk for developing contractures as a result of disuse syndrome (atrophy due to loss of motor and sensory functions below the level of the injury). Performing ROM exercises every four hours will help prevent disuse syndrome. B) Encourage Jonathan to avoid stretching his Achilles tendon. INCORRECT The Achilles tendon should be stretched and exercised to prevent foot drop. C) Discuss methods to promote regular mental stimulation. INCORRECT While promoting mental stimulation may be helpful to Jonathan, it does not address the disuse syndrome brought about by SCI. D) Assess the skin for any reddened areas at least every shift. INCORRECT This addresses Jonathan's risk for skin breakdown, but it does not address disuse syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Management Considerations
Jonathan's rehabilitation nurse, an unlicensed assistive personnel (UAP), and an aide are caring for six clients on the unit.
25. Which task should the nurse delegate to the UAP? A) Teach Jonathan how to use the electric wheelchair. INCORRECT Client teaching requires the professional expertise of the nurse. It should not be assigned to the UAP. B) Assess Jonathan's ability to perform activities of daily living. INCORRECT The nurse cannot delegate any type of assessment to the UAP.
C) Measure the intake and output (I&0) for the client taking diuretics. CORRECT The UAP can obtain the I&O measurements, but any assessments about the effectiveness of diuretics remain the responsibility of the nurse. D) Discuss appropriate ways to prevent urinary tract infections. INCORRECT Client teaching requires the professional expertise of the nurse. It should not be assigned to the UAP. Points Earned:
1.0/1.0
Correct Answer(s): C
The rehabilitation nurse is observing the unlicensed assistive personnel (UAP) caring for a paraplegic client on the unit.
26. Which behavior by the UAP warrants immediate intervention by the nurse? A) The UAP is feeding the client. CORRECT The client is a paraplegic, so has the use of upper extremities. During the rehabilitation phase of care, independence must be encouraged, so the client should not be fed. B) The UAP is taking a tympanic temperature. INCORRECT Taking a tympanic temperature is a nursing task the UAP can perform. C) The UAP is emptying the Foley catheter bag. INCORRECT Emptying a Foley catheter bag is a nursing task the UAP can perform. D) The UAP is placing socks on the client's feet. INCORRECT Placing socks on the client's feet is a nursing task the UAP can perform. Points Earned:
1.0/1.0
Correct Answer(s): A
Preparing for Discharge
Jonathan tells the nurse, "I am afraid my girlfriend will leave me, but I can't blame her for leaving someone who can't even hold her hand."
27. Which intervention should the nurse implement first? A) Encourage Jonathan to talk to his girlfriend about his concerns. INCORRECT This may be implemented at a later date, but it is not the priority intervention. B) Refer Jonathan and his girlfriend to a counselor for sexual education. INCORRECT This should be done, but it is not the priority intervention. C) Ask Jonathan if he would like to share his fears about life after leaving the hospital. CORRECT The nurse should first directly address Jonathan's fears and concerns, then encourage Jonathan to talk with his girlfriend. Referral for sexual counseling and a team meeting can be initiated at a later time. D) Request a meeting with Jonathan's healthcare team. INCORRECT Although this may be needed, it is not a priority intervention at this time. Points Earned:
0.0/1.0
Correct Answer(s): C
Jonathan voices concern about how he will be able to make a living after being released from the rehabilitation unit. Prior to the accident he worked at a local factory and attended a community college. His goal was to become a fireman, like his father.
28. Which action should the nurse implement? A) Refer Jonathan to a local counselor for vocational rehabilitation. CORRECT Vocational rehabilitation counselors assist clients with disabilities in planning careers and finding jobs. Jonathan is only 22 years old, and he needs to be productive. B) Discuss the Americans with Disabilities Act with Jonathan and his mother. INCORRECT This is a bill enacted by Congress that prohibits employers from discriminating against qualified individuals with disabilities. C) Suggest that Jonathan apply for disability payments and not worry about working. INCORRECT While Jonathan may be eligible for disability payments, this action does not address his concerns or desires to make a living after he leaves the unit.
D) Reassure Jonathan that everything will be all right after he goes home. INCORRECT This is false reassurance and does not address Jonathan's concern about how he will make a living after he leaves the unit. Points Earned:
0.0/1.0
Correct Answer(s): A
Jonathan is being discharged to his mother's home. His mother and his girlfriend will work together to provide care for Jonathan. The nurse is teaching Jonathan, his mother, and his girlfriend about muscle spasticity, one of the most common complications of quadriplegia.
29. Which intervention will the nurse include when discussing ways to prevent muscle spasticity? A) Encourage Jonathan to use a footboard at all times. INCORRECT Footboards help prevent foot drop, a contracture that may occur due to disuse syndrome. It is not useful for control of muscle spasticity. B) Perform stretching exercises five to seven times each day. CORRECT Stretching exercises are an effective, non-invasive treatment for spasticity. The stretches should be held for 45 to 90 seconds. They must be done 5 to 7 times per day because the effect on spasticity generally lasts for only a few hours. C) Instruct Jonathan to lay in the prone position 2 hours daily. INCORRECT Lying prone may help prevent skin breakdown, but it will not directly control muscle spasticity. D) Take the prescribed antibiotic when the spasms occur. INCORRECT Antispasmodic mediations may be prescribed, but antibiotics are not used to treat muscle spasms. Points Earned:
1.0/1.0
Correct Answer(s): B
The nurse is discussing bladder management with Jonathan and his mother. Jonathan has a spastic (reflexic) bladder and has been wearing a condom catheter.
30. Which statement by Jonathan's mother indicates that she has an understanding of the bladder care plan designed for Jonathan?
A) "I will limit Jonathan's fluid intake so the drainage bag won't fill so quickly." INCORRECT Adequate fluid intake (2 to 3 liters per day) is necessary to promote adequate urinary output and promote hydration. B) "I should remove the condom catheter nightly to clean his penis." CORRECT Warm urine on the periurethral skin promotes bacterial growth and colonization. The condom catheter should be removed and the skin cleaned and inspected daily. C) "Once the condom catheter is applied, I do not need to check it." INCORRECT The catheter should be inspected an hour after application to ensure that it is not too tight, which would cut off circulation to the penis. D) "If the catheter is draining slowly, I should immediately catheterize Jonathan to empty the bladder." INCORRECT Jonathan's mother should first check the tubing for kinking and then review fluid intake for the day before immediately catheterizing Jonathan. She can also be taught to palpate for bladder distention. Points Earned:
1.0/1.0
Correct Answer(s): B
Multidisciplinary Team Meeting
The multidisciplinary team is meeting to discuss discharge for Jonathan. The team is concerned that Jonathan's mother and girlfriend will not be able to care for him in the mother's home. The team are not sure that the mother's home is equipped and disability ready for Jonathan.
31. Which member of the rehabilitation multidisciplinary team is responsible for ensuring that Jonathan will be discharged to a home that is equipped to care for him? A) The recreational therapist. INCORRECT This team member works to help clients continue, or develop hobbies or interests, and often works with the occupational therapist. B) The physiatrist. INCORRECT This team member is a physician who specializes in rehabilitative medicine.
C) The occupational therapist. CORRECT This team member works to develop the client's fine motor skills used for activities of daily living, and will do a home evaluation to determine what must be done so that Jonathan can function in the home as independently as possible. D) The cognitive therapist. INCORRECT This individual works primarily with clients who have experienced head injuries and have cognitive impairments. Points Earned:
1.0/1.0
Correct Answer(s): C
The of the healthcare team are evaluating the discharge teaching that Jonathan and his significant others received while in the rehabilitation unit.
32. Which area has priority according to Maslow's Hierarchy of Needs? A) Evaluation of Jonathan's ability to transfer from bed to chair. INCORRECT Safety is important but it is not the top priority. B) Instructions concerning ways to prevent urinary tract infections. CORRECT Jonathan is at risk for urinary tract infection, a common complication of a reflexic bladder. Based on Maslow's Hierarchy of Needs, physiological needs are of the highest priority. C) Issues addressing Jonathan's potential for vocational training. INCORRECT Esteem and recognition are important, but not the highest priority. D) Assurance that significant others have resources available, if needed. INCORRECT This is important, but is not the highest priority. Points Earned:
0.0/1.0
Correct Answer(s): B
Case Outcome
The house is evaluated, and with a few minor changes, it is determined that Jonathan can go to his mother's home to live. The house has been equipped with a ramp, and what was once the
dining room will now be Jonathan’s bedroom. Home health services is scheduled to visit Jonathan daily. His significant others have verbalized and accurately demonstrated the care he will need when he is discharged home. Jonathan's mother and girlfriend are excited about his discharge and think they are ready for the challenge. Tomorrow is the big day when Jonathan will be starting his new life outside the hospital as a quadriplegic. With his family's , the efforts of his healthcare team, and his strong spirit, it should be possible for Jonathan to lead a satisfying and productive life.
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